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Evaluation of transfusion incidents and near-misses in a hospital on the coast of Santa Catarina

Hematology & Transfusion International Journal
Amanda Regina Belem Lermen,1 Daiane Cobianchi da Costa,1 Edneia Casagranda Bueno,1 Larissa Vieira Pucci,2 Alexandre Geraldo1,3

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Transfusion medicine is not free of risks and their source could be both technical and human. The near-miss is a deviation from a procedure detected before its occurrence, which could result in an erroneous transfusion and/or a transfusion reaction. The incidents in turn comprise the deviations in the security policy, leading to inadequate transfusions.

This study aimed to evaluate transfusion incidents and near-misses of a transfusion agency on the coast of Santa Catarina, Brazil.The pre-analytical, analytical and post-analytical phases of the pre-transfusion tests and transfusion procedure were evaluated using forms based on the current hemotherapy legislation and filled out locally by the researchers. The obtained data were sectioned in identifications (IDs) and their respective phases. Among the evaluations, 10,562 on-site observations were counted, and nonconformities were detected in the pre-analytical and analytical phases of the pre-transfusion tests.

Nonconformities were detected due to the non-execution of the tests (6.7%), nonidentification of the patient prior to biological sample collection (69.9%) and blood component installation (75.3%). Non-follow-up of the initial transfusion was 81.9% of noncompliance. However, there were a low number of near-misses, totaling 0.10%.

In the period of this study it was possible identifying that the in loco evaluation of hemotherapy activities is important to detect incidents and near-misses. In this way, an audit of hemotherapy procedures and the training of professionals can help to reduce incidents and near-misses caused by lack of human attention.


blood transfusion, typing, crossed blood reactions, blood banks, hospital administration, risk management